Archive for October, 2009

Why are hospitals restricting visitors?

Wednesday, October 28th, 2009

Many hospitals across the US have recently decided to restrict visitors because of the H1N1 influenza epidemic. My hospital joined with the other hospitals in our region to adopt the same visitor policy and communicate one message to the public. Having all the hospitals adopt the same practice at the same time is a great idea. It reduces confusion for the public and makes the information easier to remember.

Why restrict visitors, why do it now, and why restrict certain people? This is a unique time for hospitals. We are in the middle of the largest influenza epidemic we have seen in a long time. A new influenza virus emerged last April to which few people are immune, and it will sweep across the country unchecked until we can get more people immunized. Most patients in the hospital right now are not immune, they are very susceptible to this infection, and if this virus started to spread in a hospital, it would spread quickly with devestating results. The highest incidence of infection is in children, and children are more contagious than adults when they get influenza. A person with influenza can spread it from the day prior to illness until a couple days after they recover. We call those periods the prodromal period and the convalescent period. Bottom line; people can spread influenza without knowing it.

Most hospitals have some visitor rules. Some rules vary by the type of patient; the visitation rules are often different in critical care units than in non-acute care units, different in maternity units or in cancer units, etc. Some hospitals screen visitors for contagious disease before you can go in.

Why are hospitals restricting certain ages of visitors? We chose to exclude people below age 15. Other hospitals are using 16 or 18. I don’t think it makes a big difference what age restriction you choose. The incidence of H1N1 influenza seems to drop after age 15, and people over 15 can probably be screened and their behavior controlled better than younger children. We went with the lowest age that we thought would protect our patients.

When a person is sick or injured and hospitalized, the support of their loved ones is very important to their healing. We want our patients to be supported as much as they need, and we want their supporters to feel welcome and to participate in the patient’s recovery and care. However, if the visitor is carrying a contagious disease, it is better if they do not visit the patient in the hospital.

Trick or treat or flu?

Monday, October 26th, 2009

October 31 is rapidly approaching in the US. Called Halloween, Americans observe a peculiar ritual that may make it appear that we don’t like our children very much. We make them dress in uncomfortable costumes through which they can’t see very well, walk with impaired vision around neighborhood streets at night when they can’t be seen well by vehicles, teach them to go up to complete strangers and demand they give them candy, accept whatever these complete strangers give them and eat it, and consume far more candy than is good for them. And we do it for the children.

This year is unique for Halloween because it coincides with an influenza epidemic in the population of children participating. Is there anything we should do differently this year? I can think of two things, and there are probably more. If you are distributing candy to the children in your neighborhood, as is my job each year, wash your hands well before you handle the candy. You should reach into your bag to distribute the items, and place the candy in each young pilferer’s getaway bag. Do not let the children reach their hands into your clean container of candy. Remember some of them may be sick, and their hands could contaminate all your candy.

The second thing to remember is that if your child has been sick this week with any illness with a fever, they should not go outside Halloween night and they should not handle the candy you intend to distibute to other children. I know this will be disappointing to them, but it is the safe thing to do. Halloween could be a great way to accelerate the epidemic if you don’t take these simple precautions.

Visitor limitation helps protect patients from flu

Saturday, October 24th, 2009

To ensure the safety of our patients, hospital visitors are limited to persons 15 years old or older. Visitors to OB area are limited to immediate family and family members are recommended to wear a mask. Emergency Department visitors are limited to two visitors per patient. During flu season, Bronson encourages limited visitation within all hospital areas and reminds the public that anyone with a fever, cough, sore throat or other sign of illness should not come to the hospital to visit a patient.

Ch. 3 story on visitation guidelines

Ever heard of something called squalene?

Wednesday, October 21st, 2009

I am truly amazed sometimes how some totally obscure thing suddenly becomes an item of interest and concern among so many people. This has recently happened to a substance called squalene, which I’m sure no one reading this has ever heard of unless they were a biochemistry major.

People are saying that the H1N1 influenza vaccine has squalene in it and that this is a major threat to us. Squalene is a naturally-occurring chemical that cells make for several purposes. It is made by plants and animals, and in high concentration by sharks, because it helps them float. It is a lipid (fat) chemical in the production pathway for all the sterol-type cell componants like cholesterol. We make it in our skin and it is a natural skin moisturizer. Squalene is sold as a dietary supplement for dry skin and other purported health benefits. It is in some cosmetics to produce smooth skin.

Squalene has also been used as a vaccine adjuvant. An adjuvant is a chemical that is added to a drug to intensify the effect. Vaccine adjuvants hold the vaccine around longer and allow the body to respond to it more strongly. You can reduce the dose of the vaccine if you add an adjuvant, so they are sometimes called vaccine extenders.

Although squalene has been widely and successfully used in Europe and other markets as a vaccine adjuvant, no adjuvants have ever been approved by the FDA in the US, so no US vaccines contain squalene. The H1N1 influenza vaccine given in the US does not contain squalene. It is possible that this vaccine sold in other countries may contain adjuvants, but I am only familiar with US vaccines.

Although the word squalene sounds strange and vaguely dangerous, it is not something to worry about simply because US vaccines do not have it.

My child is sick, what should I do?

Monday, October 19th, 2009

You are very fortunate if you live in a community in which H1N1 influenza is not sweeping through schools. Here in the Kalamazoo, Michigan area we are seeing an increase in cases, mostly in children, with schools as common connections between them. We will continue to see spread among children until the H1N1 vaccine is distributed more widely among school-age children.

If your child has a fever, sore throat, body aches, headache, chills and fatigue this week, it is likely that they have influenza, especially if other children in their school have the same thing. There are other respiratory viruses circulating this time of year, but nothing as common as H1N1 influenza. The CDC has a very nice Guide for Parents that answers many questions parents have about influenza.

The most important thing you should do as a parent is to accept that your child is sick and keep them home so they can get better and not spread the virus to other children. The worst thing you can do is deny their illness, give them drugs like Tylenol to reduce their fever, and pretend they are healthy. Drugs of this type are called antipyretics because they lower the body’s set temperature. Lowering a child’s fever is not what you want to do when they are sick. Fever is the body’s response to infection, and it helps the body fight the virus. Your child may feel better when they are on these drugs, but they are just as sick, just as contagious, and just as much at risk for complications, but now you removed the most sensitive indicator of trouble by giving the child drugs to cover up the problem.

Watch your sick child closely for the eight warning signs of complications shown on the CDC Guide for Parents. Call the child’s doctor if they show one or more of these signs. If not, let them rest, keep them eating and drinking, and they should get over their infection in 5 to 7 days. Don’t send them to school, don’t allow them to play sports, don’t leave them at day care with other children, and don’t take them to church or family gatherings where they could infect other vulnerable people. I would put all these things in the category of common sense. Just think about what is best for your child before you do something you might regret.

Bronson Flu Information for Patients Who Are Sick

Some churches can just make you sick

Tuesday, October 13th, 2009

There is a short article in USA TODAY about ways organizations, including churches, are reducing the risk of spreading influenza. I actually get asked this question a lot. Churches do things during gatherings that can increase the risk of disease for their participants. Examples are shaking hands, using a common cup for sacraments, and other types of physical contact by clergy or participants. Church nurseries and children’s programs can spread infections. My experience is in mainstream protestant worship settings, but you can fill in the examples of other traditions.

Churches should try to protect their participants from contagious diseases as much as possible during respiratory virus season; fall and winter. What can they do? Anything that results in direct contact, especially hand contact, or close face-to-face encounters is risky. People who are sick, especially children, should not attend group events. Waterless hand hygiene dispensers can be installed near worship spaces so people can use them on their way in and out of the facility.

Some people object to changing such practices because their particular traditions are precious to them. I see it differently. Most religious traditions have some element of seasonality to them. Judaism, Christianity and Islam all use changes in practices or liturgy to observe and celebrate the progression through the religious calendar. We can make safe practices part of the normal progression of the church year. For example, part of the advent season can involve replacing hand shaking with another meaningful action. The CDC does not have specific guidelines for controlling influenza in church settings, but their guidelines for businesses can often be applied to churches too.

Some of the people who attend worship events and other church activities are the most physically vulnerable in our communities. Churches should take seriously their responsibility to protect such people.

What does the customer want?

Thursday, October 8th, 2009

A topic causing some controversy these days is whether healthcare workers who work with sick and vulnerable patients should be immunized against influenza each year. Healthcare workers can easily pick up influenza from a patient or from outside the work setting, can become sick themselves, can give it to other patients, and take it home to their families. Annual immunization protects workers from influenza, protecting themselves and their patients. Healthcare worker immunization produces a safer environment for the worker and for the patient. Because the highest goal of any hospital is to protect their patients from avoidable harm, many hospitals are requiring employees to be immunized. Bronson is such an institution. We have required annual immunization every year since 2005.

Opposition to healthcare worker immunization requirements generally boil down to an issue of employee autonomy. These folks feel that an employer does not have the right to require an employee to do anything they don’t want to do. I have always thought that was an odd argument. Isn’t that sort of what employment is, and how it differs from being a volunteer? In return for monetary compensation, the employee agrees to act on behalf of the employer to accomplish the employer’s mission.

In the debate over the rights of healthcare employers and employees in regard to immunization, one party has not been heard from until this week; the patient. The patient should be at the center of the discussion because they are the customer. Healthcare is in most respects a business, and the ultimate definition of what a business should do is what the customer needs and wants. Any organization that does not know and try to provide what their customers want will not be in business for long.

The University of Michigan’s C. S. Mott Children’s Hospital National Poll on Children’s Health is a national polling group that measures public opinion on issues affecting children’s health. The group polled 2365 adults across the US between August 13 and 31, and asked respondents if healthcare workers should be required to take the H1N1 influenza vaccine if there was an outbreak. A total of 87 percent of people agreed or strongly agreed. I don’t know of another study that has measured what hospital customers thought about this question, but it seems to make sense. Would you want to get influenza from your healthcare provider if it could be easily avoided?

This issue comes down to a question of integrity. If your doctor or nurse recommends that you be immunized, you want to know that they follow their own advice. Before we talk about the rights of employees and employers, we should ask what the patient wants.

Which is better, the flu shot or the nasal spray?

Monday, October 5th, 2009

There are two types of influenza vaccines licensed in the US; the traditional intramuscular injection given in your arm by a syringe and needle, and a newer intranasal product that is sprayed into the nose. The most important thing to remember is that they both work. There are many small differences between them, but if you are eligible for both of them, I don’t think it makes too much difference which one you get. They have the same virus components (antigens) in them.

The intranasal vaccine is a live vaccine; it actually contains live influenza viruses that have been altered so they can’t cause disease. Live vaccines are thought by some to work better, but some people don’t like the idea of putting live viruses in their body.

All vaccines are approved by the FDA in the US for certain patient age ranges, based on the clinical trials that the manufacturer submits to the FDA. For example, four different influenza vaccines licensed to sell in the US this year have approved age ranges starting at 6 months, 2 years, 4 years, and 18 years. This is very frustrating for providers because the vaccines are all basically the same.

The intranasal route is obviously different from an intramuscular (IM) injection. The IM vaccine produces mainly what is called systemic immunity; antibody in your bloodstream. The intranasal vaccine produces mainly what is called local immunity; antibody in the fluids of your respiratory tract. The virus attacks your lungs through your respiratory tract, so there might be a theoretical advantage to the intranasal route, but that is not clear.

Is one vaccine better than the other? That is hard to say. Is one football quarterback or baseball pitcher or musician better than another? I would answer that question with maybe, maybe not, it depends, and we don’t know. I have heard all kinds of opinions. Some people say the intranasal works better in children but not in adults, that it works better as your first dose, but not for subsequent doses, that it works better for type A influenza but not for type B, that it works better against some strains of type A but not others, that it works better some years but not others, etc. I think that they both work, you should take whichever one you and your doctor decide, and you should not worry about which one to take.